Denha & Associates, PLLC Blog

When it comes to our well-being, mental health is just as important as physical health. Unfortunately, insurers haven’t always seen it this way. In the past, many health insurance companies provided better coverage for physical illness than they did for mental health disorders. This article has been prepared to help you gain a better understanding of the recently revised Affordable Care Act and its inclusion of mental and substance abuse disorders.

While almost all large group plans and most small group plans include coverage for some mental health and substance use disorder services, there are gaps in coverage and many people with some coverage of these services do not currently receive the benefit of federal parity protections.

The Affordable Care Act and its implementing regulations, building on the Mental Health Parity and Addiction Equity Act of 2008 (“MHPAEA”), will expand coverage of mental health and substance use disorder benefits and federal parity protections in three distinct ways: (1) by including mental health and substance use disorder benefits in the Essential Health Benefits; (2) by applying federal parity protections to mental health and substance use disorder benefits in the individual and small group markets; and (3) by providing more Americans with access to quality health care that includes coverage for mental health and substance use disorder services. The Affordable Care Act provides one of the largest expansions of mental health and substance use disorder coverage in a generation by expanding mental health and substance use disorder benefits and federal parity protections to an estimated 62 million Americans.

Provisions of the new law, along with the 2008 Mental Health Parity Act, represent the latest attempts to provide preventive services and comprehensive treatment for mental health that is equivalent to that provided for physical health. The law makes mental and behavioral health treatment one of 10 essential benefits required in new insurance policies sold on the federal health exchange as well as to patients on Medicaid. That provides a promising path toward comprehensive coverage of mental illness, equal to that of medical and surgical needs.

Because of the law, most health plans must now cover preventative services, like depression screening for adults and behavioral assessments for children, at no additional cost. Most plans cannot deny you coverage or charge more due to a pre-existing health condition, including mental illness.

For example, an insurance company can’t charge $40 copay for office visits to a mental health professional such as a psychologist if it only charges $20 copay for most medical/surgical office visits. The parity law also covers non-financial treatment limits. For instance, limits on the number of mental health visits allowed in a year were once common. The law has essentially eliminated such annual limits. However, it does not prohibit the insurance company from implementing limits related to “medical necessity.”

If you have concerns that your plan isn’t complying with the parity law, I would recommend you start with the human resource department for a better understanding of your coverage. If the problem persists then litigation may be necessary or the filing of a complaint to the U.S Department of Labor’s Employee Benefits Security Administration, the department which directly regulates the industry as a whole.